fellowship competitiveness

[macrocyte]

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It seems unanimous that derm-path is the most competitive fellowship, but how do the others compare. Here's the order I propose:

1) Dermpath
2) Hemepath
3) Cytopath
4) GI path
5) GYN path
6) GU path

What do you guys think?

 

[LADoc00]

It seems unanimous that derm-path is the most competitive fellowship, but how do the others compare. Here's the order I propose:

1) Dermpath
2) Hemepath
3) Cytopath
4) GI path
5) GYN path
6) GU path

What do you guys think?

No, for a number of reasons. For one, there are a TON of cyto fellowship positions, probably 2x as many that are needed. And this is nowhere near as marketable as it used to be given that breast FNAs are being replaced by cores from radiology. Pap smears too hopefully will go away with universal HPV screening. So move that down the list.

Now GYN in my opinion is near worthless, gynpath is bread and butter stuff you can get in any solid surg path year. Competition for these fellowships is limited to academic geek types who fantasize about large ovarian masses and endometrial polyps...move that down.

GI is HUGE and up-n-coming. How many solid GI fellowships are there? Maybe MAYBE 6 in the whole US: Odze at Brigham being no1, MGH, BID, UCLA (but their big guy left), Cleveland, Hopkins...the list is slim. And dont bring up UCSF please, that fellowship is 80% liver. Move that one WAY up.

GU is interesting b/c out of the blue this is hugely marketable. Okay realize Im saying "marketable" NOT useful. I can dx anything that someone who spent a year with Epstein can but in terms of marketing myself to urologists I dont have the same leverage, move this way up, there are less GU fellowship slots than GI!!

Overall my list:
1.) Derm, still king
2.) GI
3.) GU
4.) Heme
5.) Cyto
6.) Forensics (can be very competitive at the best places: NM and MiamiDade)
7.) Blood bankTM
8.) BoneSoftTissues
9.) Gyn
10.) general surg path
11.) Lung
12.) Liver (near worthless)

 

[AngryTesticle]

Thanks for sharing your insights...very much appreciate it.

I remember talking to you about derm last year. I really enjoyed my derm weeks and derm is definitely on my radar now. However, I'm certainly more than aware of the competitiveness of getting a derm fellowship and honestly, this is quite unsettling.

And I second your opinion on the GI fellowship. We have a very strong GI fellowship here with Odze at the helm.

 

[beary]

I remember talking to you about derm last year. I really enjoyed my derm weeks and derm is definitely on my radar now. However, I'm certainly more than aware of the competitiveness of getting a derm fellowship and honestly, this is quite unsettling.

I am sort of interested in derm too, because I enjoyed clinical dermatology and sat in on signout with the dermpath folks and thought it was really cool. Of course I have very little experience to base this on. But I am sort of favoring places that have a dermpath fellowship, just in case I want to do it - does this seem like a reasonable thing to do?

 

[CameronFrye]

Thanks for sharing your insights...very much appreciate it.

I remember talking to you about derm last year. I really enjoyed my derm weeks and derm is definitely on my radar now. However, I'm certainly more than aware of the competitiveness of getting a derm fellowship and honestly, this is quite unsettling.

And I second your opinion on the GI fellowship. We have a very strong GI fellowship here with Odze at the helm.

These don't sound like the musings of a future basic science researcher. Has residency already convinced you to do diagnostic work?

 

[miko2005]

No, for a number of reasons. For one, there are a TON of cyto fellowship positions, probably 2x as many that are needed. And this is nowhere near as marketable as it used to be given that breast FNAs are being replaced by cores from radiology. Pap smears too hopefully will go away with universal HPV screening. So move that down the list.

Now GYN in my opinion is near worthless, gynpath is bread and butter stuff you can get in any solid surg path year. Competition for these fellowships is limited to academic geek types who fantasize about large ovarian masses and endometrial polyps...move that down.

GI is HUGE and up-n-coming. How many solid GI fellowships are there? Maybe MAYBE 6 in the whole US: Odze at Brigham being no1, MGH, BID, UCLA (but their big guy left), Cleveland, Hopkins...the list is slim. And dont bring up UCSF please, that fellowship is 80% liver. Move that one WAY up.

GU is interesting b/c out of the blue this is hugely marketable. Okay realize Im saying "marketable" NOT useful. I can dx anything that someone who spent a year with Epstein can but in terms of marketing myself to urologists I dont have the same leverage, move this way up, there are less GU fellowship slots than GI!!

Overall my list:
1.) Derm, still king
2.) GI
3.) GU
4.) Heme
5.) Cyto
6.) Forensics (can be very competitive at the best places: NM and MiamiDade)
7.) Blood bankTM
8.) BoneSoftTissues
9.) Gyn
10.) general surg path
11.) Lung
12.) Liver (near worthless)

I am curious why heme is so far down on your list? Is just not a good field anymore?

 

[uhoh!]

Idle curiosity, but does it make sense to do a Surg Path and a Heme Fellowship? This is what I have been thinking of doing for some time now..

I am young, debt-free, AP/CP and practice- (as opposed to research-)inclined. Will doing two fellowships have a significant advantage over, say, only Heme, esp if i am thinking of private practice? Is it worth putting in that one extra year?

also, what are other combinations of fellowships which might stand me in good stead in practice?

 

[beary]

also, what are other combinations of fellowships which might stand me in good stead in practice?

I know several folks doing both surg path and cyto fellowships.

 

[AngryTesticle]

These don't sound like the musings of a future basic science researcher. Has residency already convinced you to do diagnostic work?

No. But I don't wanna spend the clinical part of my career (as limited and minimalized as it may be) just doing autopsies. Those kind of jobs are not very abundant. I want to be able to sign out cases in some specialty. That way I can have a more stable job and increase my salary. If this doesn't happen, I've wasted my time by going through medical school and I've wasted my time doing a residency. It's all about sound backup plans.

I will say this though...it's gonna be "my way or the highway". If I don't get the fellowship I want for whatever reason, that's it! I'm going straight to postdoc. I'm not gonna waste a year doing some fellowship I have absolutely no interest in (like cyto) just to wait in line for the fellowship I want. For example, this is the case for Heme and Neuro at my program. Spots are booked not just for next year but for future years as well.

There's the musings of a future scientist. How you like dem apples?

 

[uhoh!]

I know several folks doing both surg path and cyto fellowships.

I have seen them too. But, like LADoc said, there seem to be more people doing Cyto fellowships than there is a demand for them..

I was thinking like Heme and TM (all about Blood!), or maybe Surg-GI..or am I talking crazy? 😳

 

[quant]

No. But I don't wanna spend the clinical part of my career (as limited and minimalized as it may be) just doing autopsies. Those kind of jobs are not very abundant. I want to be able to sign out cases in some specialty. That way I can have a more stable job and increase my salary. If this doesn't happen, I've wasted my time by going through medical school and I've wasted my time doing a residency. It's all about sound backup plans.

I will say this though...it's gonna be "my way or the highway". If I don't get the fellowship I want for whatever reason, that's it! I'm going straight to postdoc. I'm not gonna waste a year doing some fellowship I have absolutely no interest in (like cyto) just to wait in line for the fellowship I want. For example, this is the case for Heme and Neuro at my program. Spots are booked not just for next year but for future years as well.

There's the musings of a future scientist. How you like dem apples?

Strange, I have the same thoughts........Though at times I wish I could be stupidly brave enough to say...."Screw it, Im going to do a post doc and nothing else...money and the world be damned." And then, reality sets in...

🙁

 

[uhoh!]

..at times I wish I could be stupidly brave enough to say...."Screw it, Im going to do a post doc and nothing else...money and the world be damned." And then, reality sets in... 🙁

Makes me thankful I have no such "research-or-bust" drive in me..its not about the money, but life is a lot simpler when the choices you face are not extremely divergent. Would hate to have to choose between creature comforts v/s doing what I love.

 

[pathdawg]

No, for a number of reasons. For one, there are a TON of cyto fellowship positions, probably 2x as many that are needed. And this is nowhere near as marketable as it used to be given that breast FNAs are being replaced by cores from radiology. Pap smears too hopefully will go away with universal HPV screening. So move that down the list.

Now GYN in my opinion is near worthless, gynpath is bread and butter stuff you can get in any solid surg path year. Competition for these fellowships is limited to academic geek types who fantasize about large ovarian masses and endometrial polyps...move that down.

GI is HUGE and up-n-coming. How many solid GI fellowships are there? Maybe MAYBE 6 in the whole US: Odze at Brigham being no1, MGH, BID, UCLA (but their big guy left), Cleveland, Hopkins...the list is slim. And dont bring up UCSF please, that fellowship is 80% liver. Move that one WAY up.

GU is interesting b/c out of the blue this is hugely marketable. Okay realize Im saying "marketable" NOT useful. I can dx anything that someone who spent a year with Epstein can but in terms of marketing myself to urologists I dont have the same leverage, move this way up, there are less GU fellowship slots than GI!!

Overall my list:
1.) Derm, still king
2.) GI
3.) GU
4.) Heme
5.) Cyto
6.) Forensics (can be very competitive at the best places: NM and MiamiDade)
7.) Blood bankTM
8.) BoneSoftTissues
9.) Gyn
10.) general surg path
11.) Lung
12.) Liver (near worthless)

Ouch, babe. The cyto slam kinda hurts. I agree to a point that there are indeed lots of cyto fellowships. However, cytology is still an integral part of pathology practice, and fellowship-trained people do it better than generalists (and thats not just my defensive cyto-trained self talking). GI path seems to be somewhat in favor, but isn't this bread and butter surgpath too? I also think heme should be higher. My list:
1) Derm
2) Heme
3) Cyto
4) GI (I'll include liver with this)
5) GU
6) TM
7) Bone/ST
8) Forensics
9) GYN
10) Gen. surgpath
11) Pulmonary

 

[LADoc00]

Ouch, babe. The cyto slam kinda hurts. I agree to a point that there are indeed lots of cyto fellowships. However, cytology is still an integral part of pathology practice, and fellowship-trained people do it better than generalists (and thats not just my defensive cyto-trained self talking). GI path seems to be somewhat in favor, but isn't this bread and butter surgpath too? I also think heme should be higher. My list:
1) Derm
2) Heme
3) Cyto
4) GI (I'll include liver with this)
5) GU
6) TM
7) Bone/ST
8) Forensics
9) GYN
10) Gen. surgpath
11) Pulmonary

Sorry for the cyto slam, cyto is absolutely a key skill, my issue is there are just way too many cyto trained pathologists nowadays and overall the field is trending away from cyto. Differentiate a fellowship that is "useful" (which cyto would be far and away no1, you see prob. 5x more cyto than derm) from those that are "marketable."

Heme was good, circa around 1 year ago. The reimbursements for flow were so crazy at one point that even small hospitals were buying million dollar equipment packages. It had been that flow was actually reimbursed similar to immunostains, on a per antibody basis. So if you had a rule out panel with 18-20 antibodies (not totally uncommon) at $95 per, you were pulling down $1800 just for the professional component (a negative takes me aroun 20 min to read and write up, do the math on a per hour billing for that)! Then you billed another $65 for the spin adequacy. That was insane money, especially if you could get your hemeoncs to order flow on every marrow and node. People flooded into heme fellowships, got phat offers and then it all changed. Now flow is a gobal fee, so where before you got $1850, now it is $500 or even less. Huge hit. People were saying flow was now even a money LOSER to do as the fees were all capped. Crazy. Anyway, lots of places that were bringing flow on line and hiring hemepath people reversed course realizing it was far more cost effective to send to USLABS/Clarient etc.

I am a hemepath person so Im being frank, I definitely would not have done a whole year of it (I still like hemepath) if I saw the writing on the wall years ago. I think heme will undergo further mass consolidation in the near future to commercial labs like Quest due to fixed asset costs required in building a cutting edge diagnostic hemelab.

*Oh and Neuropath isnt on there, it would be dead last. In fact I highly advise people to not do neuro unless 1.) you are at a very very high volume place 2.) you also do a surg path year/cyto/heme or derm to tighten your skill set 3.) you also do CP as you can see that would be a 4yearAPCP+2NP+1fellowship=7 year plan, which is freakin absurd, hence why it is dead last.

 

[CameronFrye]

No. But I don't wanna spend the clinical part of my career (as limited and minimalized as it may be) just doing autopsies. Those kind of jobs are not very abundant. I want to be able to sign out cases in some specialty. That way I can have a more stable job and increase my salary. If this doesn't happen, I've wasted my time by going through medical school and I've wasted my time doing a residency. It's all about sound backup plans.

I will say this though...it's gonna be "my way or the highway". If I don't get the fellowship I want for whatever reason, that's it! I'm going straight to postdoc. I'm not gonna waste a year doing some fellowship I have absolutely no interest in (like cyto) just to wait in line for the fellowship I want. For example, this is the case for Heme and Neuro at my program. Spots are booked not just for next year but for future years as well.

There's the musings of a future scientist. How you like dem apples?

Oh ok. I thought for a second that you were softening us up for the bombshell news that you and yaah were going to open up your own dermpath mill.

 

[pathdawg]

Sorry for the cyto slam, cyto is absolutely a key skill, my issue is there are just way too many cyto trained pathologists nowadays and overall the field is trending away from cyto. Differentiate a fellowship that is "useful" (which cyto would be far and away no1, you see prob. 5x more cyto than derm) from those that are "marketable."

Heme was good, circa around 1 year ago. The reimbursements for flow were so crazy at one point that even small hospitals were buying million dollar equipment packages. It had been that flow was actually reimbursed similar to immunostains, on a per antibody basis. So if you had a rule out panel with 18-20 antibodies (not totally uncommon) at $95 per, you were pulling down $1800 just for the professional component (a negative takes me aroun 20 min to read and write up, do the math on a per hour billing for that)! Then you billed another $65 for the spin adequacy. That was insane money, especially if you could get your hemeoncs to order flow on every marrow and node. People flooded into heme fellowships, got phat offers and then it all changed. Now flow is a gobal fee, so where before you got $1850, now it is $500 or even less. Huge hit. People were saying flow was now even a money LOSER to do as the fees were all capped. Crazy. Anyway, lots of places that were bringing flow on line and hiring hemepath people reversed course realizing it was far more cost effective to send to USLABS/Clarient etc.

I am a hemepath person so Im being frank, I definitely would not have done a whole year of it (I still like hemepath) if I saw the writing on the wall years ago. I think heme will undergo further mass consolidation in the near future to commercial labs like Quest due to fixed asset costs required in building a cutting edge diagnostic hemelab.

*Oh and Neuropath isnt on there, it would be dead last. In fact I highly advise people to not do neuro unless 1.) you are at a very very high volume place 2.) you also do a surg path year/cyto/heme or derm to tighten your skill set 3.) you also do CP as you can see that would be a 4yearAPCP+2NP+1fellowship=7 year plan, which is freakin absurd, hence why it is dead last.

I'd put neuropath second to last, just before opthomologic path (I actually knew an opthomologic path fellowship trained guy. Is there a less useful fellowship out there? I think not. The only thing they're good for is orienting the one globectomy specimen you get once every ten years).

I am thinking of going back and doing a GI path fellowship, but focused to the 2nd part of the jejunum. This way, I would be sub-subspecialized. If it isn't from the 2nd part of the jejunum, I don't want to even see it. I would know nothing about the duodenum, ileum, rest of the jejunum, liver, or remainder of the GI tract. But if you have a lesion from the middle of the jejunum, I'm your guy. I bet some affected university would hire me, just so they can brag that they have the (2nd part of the) jejunum expert. It would be a sweet gig, too. I wouldn't get paid crap, but I would look at about seven slides a year in consultation. Sweet.

 

[yaah]

Oh ok. I thought for a second that you were softening us up for the bombshell news that you and yaah were going to open up your own dermpath mill.

I like dermpath. It's kind of cool. I should say - the cases are cool and being able to make the subtle diagnoses is cool. Dermpath as a field is a pain in the ass. 95% of diagnoses are easy, and if they aren't the differential is between two things that behave exactly the same. The difference is that 5%, continuum between severely atypical nevus and melanoma as well as the subtle cutaneous lymphoma stuff. I fail to see why that small area accounts for such a competitive field, but what do I know. The competitiveness is beyond irritating. If it is so needed and so competitive, then have more fellowships.

 

[LADoc00]

I'd put neuropath second to last, just before opthomologic path (I actually knew an opthomologic path fellowship trained guy. Is there a less useful fellowship out there? I think not. The only thing they're good for is orienting the one globectomy specimen you get once every ten years).

I am thinking of going back and doing a GI path fellowship, but focused to the 2nd part of the jejunum. This way, I would be sub-subspecialized. If it isn't from the 2nd part of the jejunum, I don't want to even see it. I would know nothing about the duodenum, ileum, rest of the jejunum, liver, or remainder of the GI tract. But if you have a lesion from the middle of the jejunum, I'm your guy. I bet some affected university would hire me, just so they can brag that they have the (2nd part of the) jejunum expert. It would be a sweet gig, too. I wouldn't get paid crap, but I would look at about seven slides a year in consultation. Sweet.

I plan to become a world expert on the spindle cell nevus of Reed. I will only see clinical patients with these diabolical little lesions, in fact I plan to set up a nationwide comprehensive screening program. But, they have a strong predliction for the inner thighs of young women...the burden, the burden!

 

[pathstudent]

Hey LA DOC,

What about sending the panel off to Quest to have them run the flow and then doing billing for the diagnostic interpretation yourself? Is that worthwhile?

Also is GI really #2? It seems like everyone is going to see enough of that over a career that a few extra months in fellowship really wouldn't give you an diagnostic edge a few years out.

 

[yaah]

Also is GI really #2? It seems like everyone is going to see enough of that over a career that a few extra months in fellowship really wouldn't give you an diagnostic edge a few years out.

As stated above though, it's not about being able to diagnose the majority of lesions. It's about the credentials and being the go-to person for the challenging and rare stuff. GI is becoming popular to have because the volume of GI specimens is so high. The majority can be diagnosed with ease after a month or two of looking at GI cases. But this is true with dermpath too. And GU.

We have three amazing GI pathologists here, and seeing slides with them is an altogether different experience.

So you're right in a sense, but this is the game everyone plays. When getting contracts for business from a GI practice, for example, the pathology group that has a GI pathologist is going to have a leg up in getting a piece of that business.

 

[pathstudent]

^ My opinion iis that a guy in private practice for 5 years will have seen much more rare stuff than a guy doing a one year fellowship.

BUt I guess from strictly a superficial marketing stand point being able to say we have a "GI" trained person sounds better if you need to sell yourself to others.

 

[LADoc00]

^ My opinion iis that a guy in private practice for 5 years will have seen much more rare stuff than a guy doing a one year fellowship.

BUt I guess from strictly a superficial marketing stand point being able to say we have a "GI" trained person sounds better if you need to sell yourself to others.

Its ALL about marketing, why do think our large consumer corps spend billions a year on this crap? Why are there multimillion $$$ ads for flipping Viagra during the super bowl? You can argue what is more useful all day long, but at the end of the day the group with the fellowship trained GI and GU people will walk away with the contracts and you will be holding your nuts in your hand and crying for momma. This is the sad and f'd up thing about the path market today. This isnt superficial bro, this is what puts the spam n eggs on your kids plate, makes your Benz payments and pays your employees. i.e. this is the nuts n bolts of real life in pathlandia.

Until the ABP wises up and closes down 50% of the residency programs, the surplus in path will continue to increase already cut throat competition.

 

[pathdawg]

Its ALL about marketing, why do think our large consumer corps spend billions a year on this crap? Why are there multimillion $$$ ads for flipping Viagra during the super bowl? You can argue what is more useful all day long, but at the end of the day the group with the fellowship trained GI and GU people will walk away with the contracts and you will be holding your nuts in your hand and crying for momma. This is the sad and f'd up thing about the path market today. This isnt superficial bro, this is what puts the spam n eggs on your kids plate, makes your Benz payments and pays your employees. i.e. this is the nuts n bolts of real life in pathlandia.

Until the ABP wises up and closes down 50% of the residency programs, the surplus in path will continue to increase already cut throat competition.

Truth be told, the souless *****ic bean counters who make the decisions on granting contracts aren't even sure what "GI" stands for. They don't give contracts based on credentials. They give them based on cost. To them, cheaper=better. Plain and simple. If you can underbid your competitor, you win. This is how the sweatshops like Quest and Labcorp of the world get by. They are mills and they can thus get by with low contracts by producing huge volume.

btw, I agree with your point on cutting the residency spots 1000%. This would greatly increase our earning potential.

 

[beary]

btw, I agree with your point on cutting the residency spots 1000%. This would greatly increase our earning potential.

Sounds good, just not until Match Day this year. 🙂

 

[pathstudent]

Its ALL about marketing, why do think our large consumer corps spend billions a year on this crap? Why are there multimillion $$$ ads for flipping Viagra during the super bowl? You can argue what is more useful all day long, but at the end of the day the group with the fellowship trained GI and GU people will walk away with the contracts and you will be holding your nuts in your hand and crying for momma. This is the sad and f'd up thing about the path market today. This isnt superficial bro, this is what puts the spam n eggs on your kids plate, makes your Benz payments and pays your employees. i.e. this is the nuts n bolts of real life in pathlandia.

Until the ABP wises up and closes down 50% of the residency programs, the surplus in path will continue to increase already cut throat competition.

Thanks for your opinion.

But again I ask...I know you can have Quest or some other mill run the flow for you but not have it interpreted, if you so choose, and then interpret it yourself. How much do medicare and most insurance companies pay for interpreting your average flow report?

 

[pathstudent]

Truth be told, the souless *****ic bean counters who make the decisions on granting contracts aren't even sure what "GI" stands for. They don't give contracts based on credentials. They give them based on cost. To them, cheaper=better. Plain and simple. If you can underbid your competitor, you win. This is how the sweatshops like Quest and Labcorp of the world get by. They are mills and they can thus get by with low contracts by producing huge volume.

btw, I agree with your point on cutting the residency spots 1000%. This would greatly increase our earning potential.

But fortunately the clinicians can send their specimens to whoever they wish. And for the most part clincians like to know their pathologist. That gives the private groups a real edge. The private groups know the clincians as colleagues at the hospital while the US LABS, Quest, and Ameripath people are just a bunch of faceless names signing out cases in some cubicle in some strip mall with no contact with anyone.

Whatever you do, don't take a job with a path mill. No matter how high your salary is, they are still taking 25-50% off the top. Just say no to path mills. If we all do, they will go under.

 

[drPLUM]

But fortunately the clinicians can send their specimens to whoever they wish. And for the most part clincians like to know their pathologist. That gives the private groups a real edge. The private groups know the clincians as colleagues at the hospital while the US LABS, Quest, and Ameripath people are just a bunch of tools signing out cases in some cubicle in some strip mall with no contact with anyone.

Whatever you do, don't take a job with a path mill. No matter how high your salary is, they are still taking 25-50% off the top. Just say no to path mills. If we all do, they will go under.

I've always wondered about this...

Everyone I meet seems to agree that path mills are the worst jobs and that no one should take them. However, they seem to have plenty of pathologists to read their slides. So obviously pathologists are taking jobs with these mills even though most agree it is a bad idea. So why would a pathologist take a job like this? Money? benefits? Hours? Just curious...

 

[pathstudent]

^Supposedly some of them do pay well, especially coming right out of training, like the ones where you sign-out 100 dermpath cases a day. Let's say they offer you 300,000 a year right out of training (a giant number compared to what your friends going into private groups or staying in academics are getting) But when you break it down, you are getting screwed. Let's say you are looking at 200 specimens a day (which is probably like 30-50 cases a reasonable number for grinding out biopsy after biopsy) and the company gets paid $30 per specimen for the "gross/micro" diagnosis plus interpretation of any needed special stains/immunos ($30 is probably a low figure for that). Your professional intepretation alone is generating $6000 per day. Let's say you get 8 weeks of vacation a year (again a generous number) and are working 44x5=220 days a year. You would be generating over 1.2 million in income for the company. Even after they pay for your cubicle, buy your malpractice ins, health ins, and 401k, they still have well over $1,000,000. THere's no way any of those jobs pay like that. You would be fortunate to even get half of that.

The people who go into path mills probably do so because:
A) They have to stay in a certain metro and it's a an available job
B) They think they are getting paid more not realizing that they are getting screwed
C) They think working at a hospital and dealing with clincians and frozen sections is too much of a hassle.
D) They feel that because they did the fellowship they have to find a job where that is all they do.

 

[pathdawg]

How much do medicare and most insurance companies pay for interpreting your average flow report?

Believe it or not, not as much as they pay for just performing the test.